Bevacizumab Could Increase Access to Anti-VEGFs in Treating Eye Conditions

The cost of anti—vascular endothelial growth factor (anti-VEGF) treatments for eye disorders has proven to be a challenge in providing equitable access to patients while controlling treatment costs. A newly published longitudinal study of hospital prescribing costs, set in England’s National Health Service (NHS), sought to describe growth in the use and cost of—as well as patient access to—these agents. The researchers found that current national regulations discourage the use of the more cost-effective bevacizumab and lead to unequal patient access to higher-cost ranibizumab and aflibercept in treating eye conditions.

Clinical commissioning groups (CCGs), which are responsible for commissioning healthcare for local populations in the United Kingdom, in concert with cost-effectiveness criteria established by the National Institute for Health and Care Excellence (NICE), have found that commissioning anti-VEGF medicines for patients with eye conditions has been a unique challenge. Two drugs, ranibizumab and aflibercept, are cleared by NICE to treat neovascular age-related degeneration, diabetic macular edema, retinal vein occlusion, and myopic choroidal neovascularization. The drugs have a per-injection cost to England’s NHS of approximately £550 and £800 (approximately $719 and $1045), respectively.

However, another anti-VEGF agent, bevacizumab, was not evaluated by NICE for the treatment of these conditions. Bevacizumab, which is approved for the treatment of cancer but not of ophthalmological indications, can be divided into smaller doses for ophthalmic therapy, and each injection carries a far lower cost burden at £50 to £100 (approximately $65 to $131). Bevacizumab has been demonstrated to be effective in the treatment of eye diseases, and to be more cost-effective than the 2 NICE-approved treatments.

In the study, William Hollingworth, PhD, and colleagues used Hospital Episode Statistics (HES), which are routinely collected data sets recording all episodes of care in NHS hospitals, and extracted data from hospital prescribing cost reports to estimate the costs of ranibizumab and aflibercept since 2008. The researchers also drew from a 2015 study that estimated prevalence of ranibizumab, aflibercept, and bevacizumab injections for the treatment of eye conditions at 61.1%, 36.0%, and 2.8% of treatments, respectively.

The researchers found that:

• The number of injection procedures rose by 215%, from 123,006 in 2010 to 2011 to 388 ,031 in 2014 to 2015
• The total cost to hospitals prescribing ranibizumab and afilbercept increased by 197%, from £129  million (approximately $169 million) in 2010 to 2011 to £383 million (approximately $500 million) in 2014 to 2015
• The estimated total cost of ranibizumab and aflibercept was £447 million (approximately $584 million) in 2015 to 2016

Interestingly, not all regions of the United Kingdom shared the same rates of procedures; substantial variation in access to anti-VEGF treatment was present within areas served by the same CCGs; for example, in the areas of Somerset and Wiltshire, relatively high procedure rates were evident near the cities of Bath, Bristol, and Swindon. However, procedure rates were lower in other areas in the same CCGs.

Use of bevacizumab could help to remediate the problem of high costs of and unequal access to these drugs, according to the authors, who point to existing data that suggest the NHS could save £102 million (approximately $133 million) per year by switching from ranibizumab to bevacizumab. Such a switch could help to address the “considerable potential unmet need in some areas of the country.”

The authors conclude that current regulations encourage the increased use of ranibizumab and aflibercept rather than bevacizumab, which could be a more cost-effective alternative. “This limits the ability of NHS to pay for care for other patients,” the authors say, and caution that “NHS patients in England do not have equal access to the most cost-effective care.”